Testicular cancer

 Reference: https://ascopubs.org/doi/10.1200/JCO.2014.56.0896

1. Seminomas were more radiation-sensitive. For patients with pure seminoma, orchiectomy was followed by RPLND or radiation to pelvic and para-aortic lymph nodes. Either approach resulted in similar survival; therefore, postorchiectomy radiation became standard practice. A 95% cure rate was reported in patients with seminoma treated with orchiectomy and radiation therapy. If distant metastases were found, radiation was given to the abdomen, mediastinum, supraclavicular area and even to lung metastases. 

-Today, the treatment options for stage I seminoma following orchiectomy include surveillance, 20 Gy radiation to the ipsilateral RPLN′s, or one to two cycles of carboplatin. Long-term survival is nearly 100%, irrespective of the initial option chosen.

-For patients with low volume (< 3 cm LN) stage II seminoma, 30 to 36 Gy radiation to the para-aortic and ipsilateral iliac lymph nodes remains standard.

-chemotherapy (regimen of bleomycin, etoposide, and cisplatin [BEP] × 3 or regimen of etoposide and cisplatin [EP] × 4) is preferred for patients with bulkier disease.

-residual mass > 3 cm after chemo--> PET--> SUV more than 4--> surgical resection

2.  Given the relative radiation-resistance of embryonal carcinoma, RPLND soon replaced radiation if nonseminomatous germ cell tumors (NSGCT) were present.

3. RPLND replaced radiation for patients with stage I or II NSGCT, achieving cures in nearly 50% of patients with nonmetastatic, lymph node (LN) –positive disease.

4. What can you find at RPLND and how does that affect the next steps? You may find:

-necrosis

- teratoma:  the presence of teratoma in the orchiectomy is predictive of teratoma in the RPLN

-or viable germ cell tumor (GCT)

-One area of management which remains unsettled is the role of PC-RPLND in patients with stage II or III disease achieving a serologic and radiographic complete response (CR). Proponents of observation at Indiana University cite the 15-year cancer-specific survival of 97% reported with this approach,29 while investigators at MSKCC recommend PC-RPLND in most patients, citing the presence of viable GCT and teratoma in some patients with normal-size RPLNs on CT

5.  Non seminomas Stage I: active surveillance, nerve-sparing RPLND or adjuvant chemotherapy, are standard for stage I NSGCT, resulting in 98% to 100% long-term cure rates.  Patients are characterized as high risk (relapse rates 50% with surveillance) versus low risk (15% relapse rates with surveillance) based on the presence of vascular invasion and embryonal predominant histology.

6. low volume stage II NSGCT (RPLN < 3 cm) and normal postorchiectomy hCG and AFP are generally managed with RPLND, while those with higher volume stage II disease or rising markers receive chemotherapy (BEP × 3 or EP × 4). Cures are achieved in approximately 95% of all patients

7. Seminoma has only good risk and intermediate. Intermediate BEP 4 or VIP.

8. Non seminoma has good, intermediate and poor risk. Intermediate and poor risk BEP 4.

No role for PET to assess post chemo masses in non seminoma ( can do in seminoma).

Examples of various stages of non seminoma

1. 30 yo M who underwent inguinal orchiectomy for left testicular mass. Post orchiectomy labs are normal. Path shows embryonal cell ca involving the spermatic cord. CT scan with no enlarged nodes or mets. What is his stage? 

T3N0M0 S0

Ans: stage I B, non seminoma.  Only if the tumor is limited to the testes and without any LVI, scrotal or spermatic cord invasion can it be stage IA. Otherwise T2, T3 or T4 tumors even if S0, N0, M0 should be considered IB. Predominant embryonal is also a high risk in stage I.

For stage IA-surveillance, RPLND or 1 cycle BEP are options

IB- get a CT within 4 weeks before 1 cycle BEP. RPLND or surveillance are also options.

2. 30 yo M left orchiectomy for choriocarcinoma. pT3. Persistent tumor marker elevation but no nodes, no mets. What is his stage?

Ans: stage I S ( any T stage, N0, M0 but with persistent tumor markers)--> IS

The management of IS is lumped with stage II and good risk III  ie IIIA

For non seminoma, if you have disease in the lymph nodes (N1-N3), but serum markers are still S0 or S1, you have stage II disease.

All patients undergo orchiectomy. Post orchiectomy get tumor markers and CT scan. If tumor markers are persistently elevated, BEP 3 cycles. Omit bleomycin if lung or kidney disease or over 50 yr. Within a month after chemo, get a CT CAP. No role for PET.  If residual mass 1 cm or bigger--RPLND.

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